Validation of Tokyo Guideline 2013 as Treatment of Acute Cholecystitis by Real World Data

Abstract

Background: The Tokyo Guidelines (TG; 2013) indicated that emergency cholecystectomy is an important early treatment option for acute cholecystitis; however, surgical intervention is not necessarily indicated in patients with advanced age. We evaluated percutaneous transhepatic gallbladder aspiration (PTGBA), percutaneous transhepatic gallbladder drainage (PTGBD), and the administration of antibiotics alone as treatment options for acute ­cholecystitis. Methods: From January 2010 to December 2017, 159 patients with acute cholecystitis were treated at our institution. The data from these patients were retrospectively analyzed. Results: Of these 159 cases, 109 underwent PTGBA, 28 underwent PTGBD, and 22 were administered antibiotics alone. None of the 159 patients needed urgent (early) cholecystectomy, and all patients were discharged without mortality. PTGBA was unsuccessful in only 6 of 109 patients; PTGBD was performed in these 6 cases. Long-term follow-up was conducted in all cases. Of the 159 patients, 146 had gallbladder stones initially, while 13 had none at the time of presentation. Of these 146 patients with gallbladder stones, 84 underwent elective cholecystectomy, while 62 did not. Of the 84 patients who underwent elective cholecystectomy, 2 developed choledocholithiasis; of the 62 patients who did not undergo elective cholecystectomy, 5 developed choledocholithiasis and 2 developed acute cholecystitis. The incidences of choledocholithiasis and acute cholecystitis did not significantly differ between the 2 groups (p = 0.06). Conclusions: Despite the recommendations in the TG (2013), emergency cholecystectomy was not needed in any of the present patients with acute cholecystitis. Acute cholecystitis can be successfully treated with ­PTGBA or PTGBD, which are simple procedures with good short- and long-term safety. These procedures are highly recommended for patients with acute cholecystitis, especially in the elderly population.

Patterns of prevalence and contemporary clinical management strategies in complicated acute biliary calculous disease: an ESTES ‘snapshot audit’ of practice

“…Biliary calculi, while predominantly a common benign asymptomatic entity, may also produce acute complications—such as complicated cholecystitis, choledocholithiasis with/without cholangitis, and biliary pancreatitis—requiring urgent hospital presentation for surgical care [ 1 , 2 ]. These complications may be morbid and are complex to manage [ 3 – 5 ]. Despite the frequency of presentation of these patients, there remains some clinical equipoise around the optimal timing of diagnostic investigations, the timing of surgical, endoscopic, or percutaneous interventional radiologic therapies [ 6 – 9 ].…”

Self-reported and actual adherence to the Tokyo guidelines in the European snapshot audit of complicated calculous biliary disease

“…Guidelines have had variable effect on changing physician behaviour, however, and a number of studies 16,[19][20][21][22] have examined clinician adherence to these guidelines as process measures of quality of care. This literature may be compromised by an overreliance on self-report measures of guideline adherence, because of possible response biases in self-reports 4,[16][17][18]20 . Furthermore, several inherent barriers have been shown to exist in guideline adherence, namely lack of familiarity, agreement, self-efficacy and external inhibiting factors, outcome expectancy, and the inertia of previous practice 19 .…”

“…Incremental improvements in patient outcomes for certain common surgical conditions are achievable by the standardization of patient care through practice management guidelines 4,16–18 . In complex conditions, small cumulative relative risk reductions may be attached to early diagnosis, risk stratification, appropriate resuscitation and directed antimicrobial therapy, as well as prompt surgical, endoscopic or percutaneous radiological intervention 4,17 . Clinical practice guidelines are ‘systematically‐developed statements designed to assist practitioner decisions about appropriate healthcare interventions for specific clinical circumstances’ 19 .…”

“…The present authors hypothesized that, although regional and patient heterogeneity may account for some of the variability that could be expected in different clinical practices to treat these conditions, other causes such as unit policies and individual surgeon preference might also influence the treatment decisions 4,13 . In this study, 25 different hospitals across Europe and North America were studied to investigate whether heterogeneity in practice and divergence from TG18 guidance was reflective of guideline awareness, individual surgeon preference, differences in models of acute surgical care delivery, or simply the exigencies of real‐world limitations on practice.…”

“…Acute complications of biliary calculi, such as complicated cholecystitis, choledocholithiasis with or without cholangitis, and biliary pancreatitis, commonly require urgent hospital admission for surgical care 1,2 . These conditions are morbid and complex to manage 1,[3][4][5][6] . Despite the frequency of presentation of these patients, clinical equipoise remains around the optimal timing and mode of therapy [7][8][9][10] .…”